Antidepressants
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PDL Status Values
Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the
Non-Preferred Drugs in Select PDL Classes prior authorization criteria.
New drugs will be listed as N until reviewed by the P&T Committee and are subject to the
New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.
To request a Prior Authorization, please use this form.
| Generic Name | Brand Name | Form | PDL Status |
Current Drug Use Criteria | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| amitriptyline HCl | ELAVIL | TABLET | Y | Age Restriction | Y | |
| amitriptyline HCl | AMITRIPTYLINE HCL | TABLET | Y | Age Restriction | Y | |
| bupropion HCl | BUPROPION XL | TAB ER 24H | Y | Y | ||
| bupropion HCl | WELLBUTRIN SR | TAB SR 12H | Y | Y | ||
| bupropion HCl | BUPROPION HCL SR | TAB SR 12H | Y | Y | ||
| bupropion HCl | BUPROPION HCL | TABLET | Y | Y | ||
| citalopram hydrobromide | CITALOPRAM HBR | SOLUTION | Y | Y | ||
| citalopram hydrobromide | CITALOPRAM HBR | TABLET | Y | Y | ||
| citalopram hydrobromide | CELEXA | TABLET | Y | Y | ||
| desipramine HCl | DESIPRAMINE HCL | TABLET | Y | Age Restriction | Y | |
| desvenlafaxine succinate | DESVENLAFAXINE SUCCINATE ER | TAB ER 24H | Y | Y | ||
| desvenlafaxine succinate | PRISTIQ | TAB ER 24H | Y | Y | ||
| doxepin HCl | DOXEPIN HCL | CAPSULE | Y | Age Restriction | Y | |
| doxepin HCl | DOXEPIN HCL | ORAL CONC | Y | Age Restriction | Y | |
| duloxetine HCl | DULOXETINE HCL | CAPSULE DR | Y | Y | ||
| duloxetine HCl | CYMBALTA | CAPSULE DR | Y | Y | ||
| escitalopram oxalate | ESCITALOPRAM OXALATE | TABLET | Y | Y | ||
| escitalopram oxalate | LEXAPRO | TABLET | Y | Y | ||
| fluoxetine HCl | PROZAC | CAPSULE | Y | Y | ||
| fluoxetine HCl | FLUOXETINE HCL | CAPSULE | Y | Y | ||
| fluoxetine HCl | FLUOXETINE HCL | SOLUTION | Y | Y | ||
| fluoxetine HCl | FLUOXETINE HCL | TABLET | Y | Y | ||
| fluvoxamine maleate | FLUVOXAMINE MALEATE | TABLET | Y | Y | ||
| imipramine HCl | IMIPRAMINE HCL | TABLET | Y | Age Restriction | Y | |
| mirtazapine | MIRTAZAPINE | TAB RAPDIS | Y | Y | ||
| mirtazapine | REMERON | TAB RAPDIS | Y | Y | ||
| mirtazapine | REMERON | TABLET | Y | Y | ||
| mirtazapine | MIRTAZAPINE | TABLET | Y | Y | ||
| nefazodone HCl | NEFAZODONE HCL | TABLET | Y | Y | ||
| nortriptyline HCl | NORTRIPTYLINE HCL | CAPSULE | Y | Age Restriction | Y | |
| nortriptyline HCl | PAMELOR | CAPSULE | Y | Age Restriction | Y | |
| nortriptyline HCl | NORTRIPTYLINE HCL | SOLUTION | Y | Age Restriction | Y | |
| paroxetine HCl | PAROXETINE HCL | TABLET | Y | Y | ||
| paroxetine HCl | PAXIL | TABLET | Y | Y | ||
| sertraline HCl | SERTRALINE HCL | ORAL CONC | Y | Y | ||
| sertraline HCl | ZOLOFT | ORAL CONC | Y | Y | ||
| sertraline HCl | SERTRALINE HCL | TABLET | Y | Y | ||
| sertraline HCl | ZOLOFT | TABLET | Y | Y | ||
| venlafaxine HCl | EFFEXOR XR | CAP ER 24H | Y | Y | ||
| venlafaxine HCl | VENLAFAXINE HCL ER | CAP ER 24H | Y | Y | ||
| venlafaxine HCl | VENLAFAXINE HCL | TABLET | Y | Y | ||
| amoxapine | AMOXAPINE | TABLET | V | Age Restriction | Y | |
| bupropion HCl | FORFIVO XL | TAB ER 24H | V | Y | ||
| bupropion HCl | BUPROPION XL | TAB ER 24H | V | Y | ||
| citalopram hydrobromide | CITALOPRAM HBR | CAPSULE | V | Y | ||
| citalopram hydrobromide | CITALOPRAM HBR | SOLUTION | V | Y | ||
| clomipramine HCl | ANAFRANIL | CAPSULE | V | Age Restriction | Y | |
| clomipramine HCl | CLOMIPRAMINE HCL | CAPSULE | V | Age Restriction | Y | |
| desvenlafaxine | DESVENLAFAXINE ER | TAB ER 24H | V | Y | ||
| dextromethorphan HBr/bupropion | AUVELITY | TAB IR ER | V | Y | ||
| duloxetine HCl | DRIZALMA SPRINKLE | CAP DR SPR | V | Y | ||
| escitalopram oxalate | ESCITALOPRAM OXALATE | CAPSULE | V | Y | ||
| escitalopram oxalate | ESCITALOPRAM OXALATE | SOLUTION | V | Y | ||
| esketamine HCl | SPRAVATO | SPRAY | V | Pharmacy PA | Y | |
| fluoxetine HCl | FLUOXETINE DR | CAPSULE DR | V | Y | ||
| fluvoxamine maleate | FLUVOXAMINE MALEATE ER | CAP ER 24H | V | Y | ||
| gepirone HCl | EXXUA | TAB ER 24H | V | Y | ||
| gepirone HCl | EXXUA | TAB24HDSPK | V | Y | ||
| imipramine pamoate | IMIPRAMINE PAMOATE | CAPSULE | V | Age Restriction | Y | |
| isocarboxazid | MARPLAN | TABLET | V | Y | ||
| levomilnacipran HCl | FETZIMA | CAP SA 24H | V | Y | ||
| levomilnacipran HCl | FETZIMA | CAP24HDSPK | V | Y | ||
| olanzapine/fluoxetine HCl | OLANZAPINE-FLUOXETINE HCL | CAPSULE | V | Y | ||
| paroxetine HCl | PAROXETINE HCL | ORAL SUSP | V | Y | ||
| paroxetine HCl | PAROXETINE ER | TAB ER 24H | V | Y | ||
| paroxetine HCl | PAROXETINE CR | TAB ER 24H | V | Y | ||
| paroxetine HCl | PAXIL CR | TAB ER 24H | V | Y | ||
| phenelzine sulfate | NARDIL | TABLET | V | Y | ||
| phenelzine sulfate | PHENELZINE SULFATE | TABLET | V | Y | ||
| protriptyline HCl | PROTRIPTYLINE HCL | TABLET | V | Age Restriction | Y | |
| selegiline | EMSAM | PATCH TD24 | V | Y | ||
| sertraline HCl | SERTRALINE HCL | CAPSULE | V | Y | ||
| tranylcypromine sulfate | TRANYLCYPROMINE SULFATE | TABLET | V | Y | ||
| trazodone HCl | RALDESY | SOLUTION | V | Y | ||
| trazodone HCl | TRAZODONE HCL | TABLET | V | Y | ||
| trimipramine maleate | TRIMIPRAMINE MALEATE | CAPSULE | V | Age Restriction | Y | |
| venlafaxine besylate | VENLAFAXINE BESYLATE ER | TAB ER 24 | V | Y | ||
| venlafaxine HCl | VENLAFAXINE HCL ER | TAB ER 24 | V | Y | ||
| vilazodone HCl | VILAZODONE HCL | TABLET | V | Y | ||
| vilazodone HCl | VIIBRYD | TABLET | V | Y | ||
| vortioxetine hydrobromide | TRINTELLIX | TABLET | V | Y | ||
| zuranolone | ZURZUVAE | CAPSULE | V | Pharmacy PA | Y | |
| fluoxetine HCl | FLUOXETINE HCL | CAPSULE | Y | |||
| nortriptyline HCl | NORTRIPTYLINE HCL | CAPSULE | Age Restriction | Y | ||
| olanzapine/fluoxetine HCl | OLANZAPINE-FLUOXETINE HCL | CAPSULE | Y |